ptualization
Clinical Case
Reason for Referral
A brief description of the client/patient, explanation as to the reason(s) the client has been referred to you and why they are entering treatment now.
History of the Present Illness
A detailed chronological description of problems and concerns experienced by the client, including onset, frequency, intensity, and duration of symptoms.
Social and Family History
Describe family constellation and family relationships for current family and family of origin. Discuss any outstanding events or abnormal situations in family, relationships with peers, authority figures and community supports.
Legal History and/or Financial Issues
Include any serious encounters with the law and/or any current financial stressors. Indicate how this information about the client might impact your work together in treatment?
Religious/Spiritual Practices (Current and Historical)
Indicate religious/spiritual belief system(s) if any. Reveal if different from family of origin and why. Indicate how this information about the client might impact your work together in treatment?
History of Employment and Education
Discuss employment and education history. How might having this information about the client impact your work together in treatment?
Psychological/Counseling / Psychiatric History
Include reasons for past treatment, type, outcomes, suicide attempts, hospitalizations and diagnoses. How might this information impact creating and achieving treatment goals?
Medical History/ Medications/ Psychological History
Discuss date of last physical, present state of health and any medical conditions. Indicate current medications, reason for usage and reported client side effects. Include sexual history, special diets, eating or sleeping problems. How might this information impact creating and achieving treatment goals?
History of Addictive Behavior
Discuss the nature of addiction(s) and impact on emotional, physical, relational health. How might this information impact creating and achieving treatment goals?
Mental Status & Behavioral Observations:
Provide behavioral observations and mental status of client. How might this information impact creating and achieving treatment goals?
Ethical Considerations
Address 2-3 specific ethical and/or legal considerations for this case. Choose one of these issues addressed, to review in depth using a specific ethical decision making model. Indicate the model used. How might this information impact creating and achieving treatment goals?
Cultural Factors/Multicultural Competence
Discuss the multicultural considerations (e.g., gender, age, ability, sexual orientation, ethnicity, socioeconomic status, religion, class, and/or culture) that are evident for this case. Describe and apply the tenets of a relevant multicultural theory or model as it pertains to this case. Discuss what counselor factors comprise multicultural competence. How might this information impact diagnosis, treatment and creation of treatment goals?
Assessment:
What assessment measures would you decide to conduct to enhance your understanding of the client(s) in order to direct your diagnostic formulation?
Theoretical Formulation: Family Theory/Therapy (Case conceptualization)
a. Name a specific family theory you would use to treat this case and why you would choose this theory.
b. Describe the specific and fundamental tenets of your chosen family theory.
c. Apply the family theory to your case, specifying hypotheses based on your theory.
Theoretical Formulation: Individual Theory/Therapy (Case conceptualization)
Note: You must use a separate theory from the family theory section.
a. Name a specific individual theory you would use to treat this case and why you would choose this theory.
b. Describe the specific, fundamental tenets of the individual theory.
c. Apply the individual theory to your case, specifying hypotheses based on your theory.
Diagnostic Impressions
A. Differential Diagnosis:
B. Develop a differential diagnosis. Indicate why you are considering these possible diagnoses by providing specific evidence from your case.
C. Full Diagnosis:
D. Give a DSM-5 Diagnosis (including use of V-Codes).
Treatment Plan
Using the template below, create a treatment plan for the theory you discussed in your family theory theoretical formulation section.
Give a brief summary of the approach discussed in your theoretical formulation for family therapy, then reveal the following:
Beginning
Pertinent interventions that will be use at this stage. Include:
A. Goals: Provide a minimum of 3 specific to chosen family theory.
B. Objectives: Indicate how goals will be accomplished, specific to chosen family theory.
C. Interventions: Strategies to accomplish goals/objectives based on chosen family theory, from a multi-culturally competent perspective.
Middle
Pertinent interventions that will be use at this stage. Include:
A. Goals: Provide a minimum of 3 specific to chosen family theory.
B. Objectives: Indicate how goals will be accomplished, specific to chosen theory.
C. Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.
End
Pertinent interventions that will be use at this stage. Include:
A. Goals: Provide a minimum of 3 specific to chosen family theory.
B. Objectives: Indicate how goals will be accomplished, specific to chosen theory.
C. Interventions: Strategies to accomplish goals/objectives based on chosen theory, from a multi-culturally competent perspective.
Pertinent Resources/Referrals
What referrals might benefit the client’s treatment and why?
a. Psychopharmacology
b. Group
c. Medical

APPENDIX C
Clinical Vignette Review Guidelines
This assignment involves composition of a scholarly sounding, professionally worded, clinical analysis of the case vignette from Practicum I seminar class.
CLINICAL VIGNETTE REVIEW EXPECTATIONS:
Writing skills (25 pts):
a. APA Style, including correct citations of references used (8 pts)
b. Correct wording, organization, grammar, spelling (10 pts)
c. Ability to smoothly segue between sections (2 pts)
d. Ability to write in professional sounding (Master’s Level) “voice” (5 pts)
Case conceptualization section (60 pts):
e. Case Conceptualization is obtaining and organizing information about the client, understanding and explaining the client’s situation and maladaptive patterns using theoretical reference, guiding and focusing treatment based off theory, anticipating challenges and roadblock and preparing for a successful termination. (20 pts)
f. Indicate your impressions of the case including transference and/or counter-transference that might arise ( 5 pts)
g. Discuss existing diversity issues and how these might impact therapy. Include a discussion of your own level of multicultural competence (define) with this case and how impacts your diagnostic and treatment decisions ( 5 pts)
h. Provide up to 3 differential diagnostic considerations with clear discussion of diagnostic possibilities or rule/outs for this person. Your write up must also include a DSM- 5-diagnostic listing (5 pts)
i. Discuss 2 ethical concerns you have for this case. Indicate how you would address just 1 of these concerns guided by a specific ethical decision making model (5 pts)
j. Develop a treatment plan given the diagnoses, cultural issues, and ethical concerns you have for this case
i. Indicate what you would do at the beginning, middle and end stages of treatment. Make sure you develop your treatment with diversity and ethical concerns in mind (6 pts)
ii. Include and describe the family theory you would use with this case,with detailed interventions specific to this case and why you would use this type of theoretical perspective (6 pts)
iii. Include and describe the individual theory you would use with this case, with detailed interventions specific to this case and why you would use this type of theoretical perspective (6 p
iv. Address any referrals you might give as an adjunct to treatment and how these might be beneficial to the treatment (2pt)

Here is the Case Vignette for the paper
CLINICAL CASE REVIEW – VIGNETTE
Kemmel is a 45-year-old female of biracial Mexican/African-American heritage. She is the mother of two girls, who are age 17 and 7, by two different fathers. She comes from a family of very strict devout Christians and their socioeconomic status is lower-middle class. During her childhood, she spent most of her time isolated from other children and was not allowed to go outside, listen to secular music, or wear pants. When Kemmel was disobedient, her parents, especially her mother, would enact harsh punishments, often extreme punishment, such as ridiculing, and name-calling, physical violence, deeming and degrading and at times ostracized her from the rest of the family.
As she grew older, her father became closer to Kemmel, and he would touch her to comfort her after her mother would be upset with her. She stated he would say this is their “secret special touch.” Her mother became suspicious of this relationship and blamed Kemmel but never confronted her husband. Kemmel’s mother was jealous of her father and her relationship. She would often come up with severe and creative ways, to punish Kemmel when she saw her husband show Kemmel attention and affection that she wished he showed to her. Kemmel’s escape came when, at 15 years old, she ran away from home with one of her many boyfriends. Her determination to graduate from high school and earn her college degree helped earn her Master’s in Education and Teaching Credential. Since completing her degrees she has been gainfully employed as a teacher for 15 years.
Since she left her parents Kemmel has become distant from them, avoiding conversations or being around them; when she did have contact it was occasionally and only on special occasions. From about the age of 15 to 25, Kemmel would experience flashbacks about the traumatic way her mother treated her. While in college, she began to realize just how inappropriate her father’s touching her was. Kemmel reported that she would make comments to her boyfriends that she would never allow anyone to hurt or ridicule her children when she has some. Kemmel has been in and out of relationships hoping to find someone to love her and make her feel safe and would be safe around children. Kemmel said she has had many relationships because she was afraid of commitment and settling down with a family, she stated that she would remember how her mother treated her and felt she would repeat the cycle of abuse and did not think she could trust a man around her children.
At the age of 26, she had her first daughter, who is now 17 years old, but Kemmel does not have a good relationship with the father — she stated that she feels the father is too touchy with their daughter and he does not show Kemmel any respect. Kemmel and her 7-year old daughter’s father are fairly close and she considers him a good friend, although she reports she does not want to be in a relationship him.
Kemmel later met another man, a police officer, and she felt he was going to be the one with whom she could make her storybook family. Kemmel found out after becoming pregnant that he was cheating on her and did not want to have her or the baby in his life. She has never told anyone about her experiences growing up, and why she and her parents are not very close.

Kemmel reconnected with her parents due to a death in the family, and they really wanted to spend time getting to know their grandchildren better. Kemmel was feeling depressed about her current relationship and being six weeks pregnant and needed some time to process her feelings. Therefore, she decided to allow her children to spend a day or two with her parents to see if things were different with her children. Later, after seeing Kemmel’s parents being kind, and loving she asked them to watch her children for an extended weekend while she went away to repair her relationship with her boyfriend. During the vacation with her now ex-boyfriend, he told her that he does not want to continue with their relationship and does not want her to continue the pregnancy. Kemmel was crushed and hurt, she felt rejected and not good enough. Kemmel reported feeling down, but at the same time excited about seeing her girls, she stated that she really missed them and they always make her feel good. When she arrived to pick up her children, she observed her children mannerism and behavior to be distant and sad. She first thought that she was imagining things because she was hurt and feeling conflicted about her relationship. When she kissed her children and placed them in the car, they appeared to be clinging on to one another and talking quietly. She tried to engage them into a conversation and asked them how their weekend was while she drove away. Her 7-year old said her grandpa played a “secret touching game” with her, and the 17- year said her grandmother had taken her into a backroom while her grandfather was with her younger sister. At that time, Kemmel noticed a bruise on the 17-year-old daughter arm, which was not there when she dropped her off. The mother seemed to be fixated on what was happening and had a flashback about what happen to her.
Kemmel has been admitted to the hospital for evaluation after being arrested for brutally attacking her parents in their home. Her children who heard screaming from the house called police to the scene. Her boyfriend arrived to the scene after hearing the address on the police scanner. When the police arrived, they found the patient covered in blood, muttering in inaudible tones and appearing to be having a conversation with someone that was not there. They searched for her parents and found them barricaded in their bedroom both suffering from severe injuries.
Until recent events, the client had no recorded history of mental illness. At times the patient can be quite lucid and seems to be fully aware of what she is doing and her surroundings; at other times she is withdrawn, sullen and has incoherent conversations with herself. When questioned about her childhood, the client becomes irritated, uncomfortable, and angry (e.g., she yelled that she had “a horrible childhood.”) Most of the memories have to do with her mother’s strict and creative forms of discipline or her father’s extreme forms of affection. When asked about the incident that caused her to be admitted to the facility, she said, “I would never allow my children to be hurt like I was.” She says her parents were evil and needed to be punished, and will say nothing further about the incident.
The patient’s boyfriend has indicated early on during their relationship at times she would become withdrawn and would not want him to touch her or even in her presence. This behavior would last for a few weeks and during this time she would sleep in a separate room, but he could hear her screaming and crying at night. She would become violent whenever he went to comfort her. After a couple of weeks she would become quite affectionate and sexual before returning to herself. The behavior pattern changed and she became reckless and had self-destructive behaviors, hyper vigilance and exaggerated frighten response to his questions. He took her on a recent vacation to make some decision about Kemmel being pregnant, and if he wanted to continue in the relationship. He stated that he loved her, but he felt he did not make her happy, she seemed unable to experience happiness, satisfaction, or loving feelings towards him and others at times.
When asked about the current episode and what might have triggered it her boyfriend stated he and the client had recently returned from vacation. He said he broke off the relationship because she was trying to make him marry her, when he told her; he was not ready for marriage and a baby. Kemmel had an angry, aggressive, outburst, verbally, and physical towards him. He stated he had no idea why she would attack her parents.

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